Australia’s health 2016 PDF

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Burden of disease is a measure of the years of healthy life lost from living with, or dying from disease and injury. The summary measure ‘disability-adjusted life years’ (or DALY) measures the years of healthy life lost from death and illness."

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A ust ra l ia’s hea lth 2016

Australia’s health 2016 4.1 Social determinants of health Our health is influenced by the choices that we make—whether we smoke, drink alcohol, are immunised, have a healthy diet or undertake regular physical activity. Health prevention and promotion, and timely and effective treatment and care, are also important contributors to good health. Less well recognised is the influence of broader social factors on health (see ‘Chapter 1.1 What is health?’). Evidence on the close relationship between living and working conditions and health outcomes has led to a renewed appreciation of how human health is sensitive to the social environment. Factors such as income, education, conditions of employment, power and social support act to strengthen or undermine the health of individuals and communities. Because of their potent and underlying effects, these health-determining factors are known as the ‘social determinants of health’ (Wilkinson & Marmot 2003). The World Health Organization (WHO) has described social determinants as: …the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces (CSDH 2008). According to WHO, the social conditions in which people are born, live and work is the single most important determinant of good health or ill health. As factors that affect health, social determinants can be seen as ‘causes of the causes’—that is, as the foundational determinants which influence other health determinants. In keeping with this model, Figure 4.1.1 illustrates how social determinants extend inward to affect other factors, including health behaviours and biomedical factors that are part of a person’s individual lifestyle and genetic make-up.

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Source: Dahlgren & Whitehead 1991.

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Figure 4.1.1: A framework for determinants of health

Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW.

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Australia’s health 2016 The National Health Performance Framework also recognises the importance of social determinants to our health. The framework includes community and socioeconomic factors that relate to income, health literacy and educational attainment (see ‘Chapter 7.1 Indicators of Australia’s health’). The health advantages and disadvantages experienced by Australians are shaped by their broader social and economic conditions (see Box 4.1.1). Inequalities in health appear in the form of a ‘social gradient of health’, so that in general, the higher a person’s socioeconomic position, the healthier they are. Some health inequalities are attributable to external factors and to conditions that are outside the control of the individuals concerned. Inequalities that are avoidable and unjust—health inequities—are often linked to forms of disadvantage such as poverty, discrimination and access to goods and services (Whitehead 1992).

• The 20% of Australians living in the lowest socioeconomic areas in 2014–15 were 1.6 times as likely as the highest 20% to have at least two chronic health conditions, such as heart disease and diabetes (ABS 2015a). • Australians living in the lowest socioeconomic areas lived about 3 years less than those living in the highest areas in 2009–2011 (NHPA 2013). • If all Australians had the same death rates as people living in the highest socioeconomic areas in 2009–2011, overall mortality rates would have reduced by 13%—and there would have been 54,000 fewer deaths (AIHW 2014d). • People reporting the worst mental and physical health (those in the bottom 20%) in 2006 were twice as likely to live in a poor-quality or overcrowded dwelling (Mallett et al. 2011). • Mothers in the lowest socioeconomic areas were 30% more likely to have a low birthweight baby than mothers in the highest socioeconomic areas in 2013 (AIHW 2015a). • A higher proportion of people with an employment restriction due to a disability lived in the lowest socioeconomic areas (26%) than in the highest socioeconomic areas (12%) in 2012 (AIHW analysis of ABS 2012 Survey of Disability, Ageing and Carers). • Unemployed people were 1.6 times as likely to use cannabis, 2.4 times as likely to use meth/amphetamines and 1.8 times as likely to use ecstasy as employed people in 2013 (AIHW 2014e). • Dependent children living in the lowest socioeconomic areas in 2013 were 3.6 times as likely to be exposed to tobacco smoke inside the home as those living in the highest socioeconomic areas (7.2% compared with 2.0%) (AIHW analysis of the 2013 National Drug Strategy Household Survey). • People in low economic resource households spend proportionally less on medical and health care than other households (3.0% and 5.1% of weekly equivalised expenditure, respectively, in 2009–10) (ABS 2012). • People living in the lowest socioeconomic areas in 2014–15 were more than twice as likely to delay seeing—or not see—a dental professional due to cost compared with those living in the highest socioeconomic areas (28% compared with 12%) (ABS 2015b).

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Box 4.1.1: Ten facts about social determinants and health inequalities

2 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW.

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Australia’s health 2016 Key social determinants of health The evidence gathered from the ways in which social, economic, political and cultural conditions create health inequalities has led to the identification of key social determinants of health and wellbeing (CSDH 2008; Wilkinson & Marmot 2003), including socioeconomic position, early life circumstances, social exclusion, social capital, employment and work, housing and the residential environment.

Socioeconomic position In general, people from poorer social or economic circumstances are at greater risk of poor health, have higher rates of illness, disability and death, and live shorter lives than those who are more advantaged (Mackenbach 2015). Generally, every step up the socioeconomic ladder is accompanied by an increase in health. Historically, individual indicators such as education, occupation and income have been used to define socioeconomic position (Galobardes et al. 2006). • Educational attainment is associated with better health throughout life. Education equips people to achieve stable employment, have a secure income, live in adequate housing, provide for families and cope with ill health by assisting them to make informed health care choices. An individual’s education level affects not only their own health, but that of their family, particularly dependent children. • Occupation has a strong link to position in society, and is often associated with higher education and income levels—a higher educational attainment increases the likelihood of higher-status occupations and these occupations often come with higher incomes. • Income and wealth play important roles in socioeconomic position, and therefore in health. Besides improving socioeconomic position, a higher income allows for greater access to goods and services that provide health benefits, such as better food and housing, additional health care options, and greater choice in healthy pursuits. Loss of income through illness, disability or injury can adversely affect individual socioeconomic position and health (Galobardes et al. 2006).

The foundations of adult health are laid in-utero and during the perinatal and early childhood periods (Lynch & Smith 2005). The different domains of early childhood development—physical, social/emotional and language/cognitive—strongly influence learning, school success, economic participation, social citizenry and health (CSDH 2008). Healthy physical development and emotional support during the first years of life provide building blocks for future social, emotional, cognitive and physical wellbeing. Children from disadvantaged backgrounds are more likely to do poorly at school, affecting adult opportunities for employment, income, health literacy and care, and contributing to intergenerational transmission of disadvantage. Investment in early childhood development has great potential to reduce health inequalities, with the benefits especially pronounced among the most vulnerable children (Heckman & Mosso 2014).

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Early life

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Australia’s health 2016 Social exclusion Social exclusion is a broad concept used to describe social disadvantage and lack of resources, opportunity, participation and skills (Hayes et al. 2008). Social exclusion may result from unemployment, discrimination, stigmatisation and other factors. Poverty; culture and language; and prejudices based on race, religion, gender, sexual orientation, disability, refugee status or other forms of discrimination limit opportunity and participation, cause psychological damage and harm health through long-term stress and anxiety. Social exclusion can damage relationships, and increase the risk of disability, illness and social isolation. Additionally, disease and ill health can be both products of, and contribute to, social exclusion.

Social capital Social capital describes the benefits obtained from the links that bind and connect people within and between groups (OECD 2001). The extent of social connectedness and the degree to which individuals form close bonds with relations, friends and acquaintances has been in some cases associated with lower morbidity and increased life expectancy (Kawachi et al. 1997), although not consistently (Pearce & Smith 2003). It can provide sources of resilience against poor health through social support which is critical to physical and mental wellbeing, and through networks that help people find work, or cope with economic and material hardship. Social infrastructure—in the form of networks, mediating groups and organisations—is also a prerequisite for ‘healthy’ communities (Baum & Ziersch 2003). The degree of income inequality within societies (the disparity between high and low incomes) has also been linked to poorer social capital and to health outcomes for some, although there is little evidence of consistent associations (Lynch et al. 2004).

Employment and work

Rates of unemployment are generally higher among people with no or few qualifications or skills, those with disabilities or poor mental health, people who have caring responsibilities, those in ethnic minority groups or those who are socially excluded for other reasons (AIHW 2015b). Once employed, work is a key arena where many of the influences on health are played out. Dimensions of work—working hours, job control, demands and conditions—have an impact on physical and mental health (Barnay 2015). Participation in quality work is health-protective, instilling self-esteem and a positive sense of identity, while also providing the opportunity for social interaction and personal development (CSDH 2008).

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Unemployed people have a higher risk of death and have more illness and disability than those of similar age who are employed (Mathers & Schofield 1998). The psychosocial stress caused by unemployment has a strong impact on physical and mental health and wellbeing (Dooley et al. 1996). For some, unemployment is caused by illness, but for many it is unemployment itself that causes health problems through its psychological consequences and the financial problems it brings.

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Australia’s health 2016 Housing Safe, affordable and secure housing is associated with better health, which in turn impacts on people’s participation in work, education and the community. It also affects parenting and social and familial relationships (Mallet et al. 2011). There is a gradient in the relationship between health and quality of housing: as the likelihood of living in ‘precarious’ (unaffordable, unsuitable or insecure) housing increases health worsens. The relationship is also two-way, in that poor health can lead to precarious housing. Single parents and single people generally, young women and their children and older private renters are particularly vulnerable to precarious housing (AIHW 2015b; Mallet et al. 2011).

Residential environment The residential environment has an impact on health equity through its influence on local resources, behaviour and safety. Communities and neighbourhoods that ensure access to basic goods and services; are socially cohesive; which promote physical and psychological wellbeing; and protect the natural environment, are essential for health equity (CSDH 2008). To that end, health-promoting modern urban environments are those with appropriate housing and transport infrastructure and a mix of land use encouraging recreation and social interaction.

Measuring socioeconomic inequalities in health Since social determinants are often pinpointed as a key cause of health inequalities, measuring the size of the health gap between different social groups is important. This provides essential information for policies, programs and practices which seek to address social determinants in order to reduce health gaps (Harper & Lynch 2006).

Although individual measures of socioeconomic position are included in some health data sets, area-based measures can be calculated from most collections. An example is the Australian Bureau of Statistics (ABS) composite Index of Relative Socio-economic Disadvantage (IRSD), which is frequently used to stratify the population—see Box 4.1.2 for further details.

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A common approach to measurement is to: (i) rank the population by socioeconomic position; (ii) divide the population into groups based on this ranking; and (iii) compare each group on health indicators of interest. To rank the population by socioeconomic position, factors such as education, occupation or income level are commonly used, although many other factors, such as housing, family structure or access to resources, can also be used. These factors closely reflect social conditions, such as wealth, education, and place of residence (WHO 2013a). Similar associations between socioeconomic position and health are generally found regardless of which factor is used.

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Australia’s health 2016 Box 4.1.2: The Index of Relative Socio-economic Disadvantage The IRSD is one of four indices compiled by the ABS using information collected in the Census of Population and Housing (ABS 2013). This index represents the socioeconomic conditions of Australian geographic areas by measuring aspects of disadvantage. The IRSD scores each area by summarising attributes of their populations, such as low income, low educational attainment, high unemployment, and jobs in relatively unskilled occupations. Areas can then be ranked by their IRSD score and are classified into groups based on their rank. Any number of groups may be used—five is common. If five categories are used, then the IRSD commonly describes the population living in the 20% of areas with the greatest overall level of disadvantage as ‘living in the lowest socioeconomic areas’ or the ‘lowest socioeconomic group’. The 20% at the other end of the scale—the top fifth—is described as the ‘living in the highest socioeconomic areas’ or the ‘highest socioeconomic group’. It is important to understand that the IRSD reflects the overall or average socioeconomic position of the population of an area; it does not show how individuals living in the same area might differ from each other in their socioeconomic position. Often, the gap between the lowest and highest socioeconomic groups is of greatest interest. Simple differences in epidemiologic measures, such as rates and prevalences, can be used to examine this gap—and this gap can be absolute (for example, a difference in rates) or relative (for example, the ratio between two rates) (Harper et al. 2010). Both absolute and relative measures help in understanding the differences in health status between the two groups. Absolute measures are important for decision makers, especially where goals in absolute terms have been set, since they allow a better appraisal of the size of a public health problem.

Although complex measures include information on both the magnitude of inequality and the total population distribution of inequality, they are restricted by the types of data that can be used, and by their ease of interpretation.

The social gradient in health There is clear evidence that health and illness are not distributed equally within the Australian population. Variations in health status generally follow a gradient, with overall health tending to improve with improvements in socioeconomic position (Kawachi et al. 2002).

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Simple measures generally use information from only two socioeconomic groups—the lowest and highest—and ignore the middle groups. More complex measures use information from all groups to measure the magnitude of socioeconomic inequalities in health (WHO 2013a).

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Australia’s health 2016 One example is mortality (Figure 4.1.2). In 2009–2011, the female mortality rate was 518 deaths per 100,000 population in the lowest socioeconomic areas, compared with 503 in the second group, 472 in the third, 453 in the fourth, and 421 in the highest socioeconomic areas—with a 23% difference in mortality rates between the highest and lowest areas. For males, the effect was similar, with an even greater inequality (33%) between the highest and lowest areas (AIHW 2014d). Figure 4.1.2: The social gradient in Australian mortality, 2009–2011 Deaths per 100,000 population 800

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Socioeconomic group Note: Socioeconomic groups are based on the area of residence using the ABS Index of Relative Socio-economic Disadvantage. Source: AIHW 2014d.

The gradient is apparent even at young ages. Figure 4.1.4 illustrates the relationship between social exclusion and health outcomes among Australian children. Children at higher risk of social exclusion—measured using an index of socioeconomic circumstances, education, connectedness, housing and health service access—had higher rates of avoidable deaths (that is, deaths which were potentially preventable or treatable within the present health system) (AIHW 2014c). The social gradien...